This movement to a multidisciplinary patient-centred approach presents an opportunity for massage therapists to collaborate with other healthcare professionals to improve a patient’s health and treatment outcome. This transition also presents an opportunity to re-evaluate how we communicate with the medical community. Articulating the science behind massage therapy can come with some challenges, but it is my belief that we can do it in a way that will promote growth and development of the profession.
Massage therapists want to help patients, and part of our approach requires having a clear message of who we are and the value we offer. Adopting an evidence-based framework offers a solution, as it can provide a cohesive message of our nature and value. An evidence-based framework is an interdisciplinary approach to clinical practice used throughout healthcare. By adopting this approach, massage therapists will ensure that healthcare professionals consider the complex interplay between physiological and psychological factors that massage therapy affects.
Treatment approaches in massage therapy may vary, but each therapeutic encounter involves some overlapping principles. I will highlight the main principles of an evidence-based framework for massage therapy using recent scientific research.
#1 Affective touch: Therapeutic massage is a source of safety, comfort and relief
Socially appropriate interpersonal touch has been shown to stimulate the release of neurochemicals (endogenous opioids and oxytocin) associated with relaxation and pain relief (Vigotsky et al. 2015, Walker et al. 2017). A reassuring therapeutic encounter, in which a patient is provided with compassionate touch, provides the patient with a safety message. This can result in reduced physiological and behavioural reactivity to stressors and improved mood/affect.
“We will experience pain when our credible evidence of danger related to our body is greater than our credible evidence of safety related to our body. Equally we won’t have pain when our credible evidence of safety is greater than our credible evidence of danger”—Lorimer Moseley
#2 Contextual factors: Therapeutic massage provides hope
It has long been known that the way a clinician presents both themselves and their treatment, is tied to health-related outcomes - this is known as the contextual factors of a therapeutic encounter (Rossettini et al. 2018). In the book How Healing Works: Get well and stay well using your hidden power to heal, Wayne Jonas talks about creating an optimal healing environment. This involves providing a patient-centred clinical experience that embraces the placebo response and the natural healing capacity of the body (Ongaro et al. 2019). In essence, behaviours and interactions with patients facilitate a relaxation response that will help to influence health-related outcomes; the magnitude of a response is influenced by mood, expectation, and conditioning.
“By definition, CFs (Contexual Factors) are physical, psychological and social elements that characterize the therapeutic encounter with the patient. CFs are actively interpreted by the patient and are capable of eliciting expectations, memories and emotions that in turn can influence the health-related outcome, producing placebo or nocebo effects.” —Rossettini et al. 2018
#3 Mechanical factors: Therapeutic massage influences tissue and cell physiology
Researchers have investigated the effect of soft-tissue massage on cellular signalling and tissue remodelling; this is referred to as mechanotherapy. Geoffrey Bove a researcher at the University of New England has conducted research examining the effect of modelled manual therapy on repetitive motion disorders and the development of fibrosis. One study published in The Journal of Neurological Sciences showed soft-tissue massage prevented the deposition of collagen and TGF beta 1 in the nerves and connective tissues of the forearm (Bove et al. 2016). This was recently followed up by a study published in the prestigious journal Pain showing that by attenuating the inflammatory response (with modelled massage) in the early stages of an injury, they were able to prevent the development of neural fibrosis (Bove et al. 2018).
Furthermore, a recent joint research effort between Timothy Butterfield of the University of Kentucky and researchers at Colorado State University demonstrated that modelled massage enhanced satellite cell numbers (Miller et al. 2018). This was in addition to earlier research from Butterfield and his collaborators at the University of Kentucky, which proposes the idea that mechanical stimulation prompts a phenotype change of pro-inflammatory M1 macrophages into anti-inflammatory M2 macrophages (Waters-Banker et al. 2014). Taken together the increase in satellite cell numbers and reduction in inflammatory signaling may improve the body’s ability to respond to subsequent rehabilitation.
#4 Neurological factors: Therapeutic massage stimulates specialized sensory receptors
Specialized mechanoreceptors located cutaneous and subcutaneous structures are what informs the body about the type of touch they are receiving, there are five major types of mechanoreceptors that massage therapists should be aware of:
- Two of these are located in the superficial layers of the skin: Merkel cells and Meissner corpuscles.
- Two receptors, the Pacinian corpuscle and the Ruffini endings, are found in the subcutaneous and deeper tissue layers.
- The fifth type of mechanoreceptor are the recently discovered C-tactile fibers that play a specific role in transmitting the pleasurable properties of touch. (They also play a role in affective touch mentionedprior.)
Massage therapy is a form of peripheral somatosensory stimulation that can modulate the activity of neuro-immune (peripheral, cortical, subcortical) processes correlated with the experience of pain (Bialosky et al. 2018, Chimenti et al. 2018). By activating ascending and descending inhibitory systems, massage therapy may be able to mitigate the transition, ampliﬁcation and development of chronic pain.
Massage therapy is a clinically-oriented healthcare option that can improve quality of life for patients with a variety of conditions. The responses to massage therapy are multifactorial, even if the mechanisms of action have not yet been fully elucidated. There is evidence that in terms of clinical responses to massage therapy affective touch, contextual factors, mechanical factors, and neurological factors are likely to play a role.
Bialosky et al. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018 Jan;48(1):8-18.
Bove et al. Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. J Neurol Sci. 2016 Feb 15;361:168-80.
Bove et al. Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain. 2018 Nov 16.
Busse et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666.
Chimenti RL, Frey-Law LA, Sluka KA. A Mechanism-Based Approach to Physical Therapist Management of Pain. Phys Ther. 2018 May 1;98(5):302-314.
Miller et al. Enhanced skeletal muscle regrowth and remodelling in massaged and contralateral non-massaged hindlimb. J Physiol. 2018 Jan 1;596(1):83-103.
Ongaro G, Kaptchuk TJ. Symptom perception, placebo effects, and the Bayesian brain. Pain. 2019 Jan;160(1):1-4.
Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord. 2018 Jan 22;19(1):27.
Walker et al. C-tactile afferents: Cutaneous mediators of oxytocin release during affiliative tactile interactions? Neuropeptides. 2017 Aug;64:27-38.
Vigotsky AD, Bruhns RP. The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review. Pain Res Treat. 2015;2015:292805.
Waters-Banker et al Investigating the mechanisms of massage efficacy: the role of mechanical immunomodulation. J Athl Train. 2014 Mar-Apr;49(2):266-73.
Richard Lebert works in Petrolia Ontario and is associate faculty at Lambton College. Richard runs an online resource (RMTedu.com) exploring long-term solutions that promote growth and development of the profession. When he is not in the clinic his favorite activities are hiking, camping and kayaking with family and friends.